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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District VE- 7 Job Address N/��ste -230 VTarn_acCus7l��l a �} �of City /Z; aLot Size Owner's Name � n Phone Contractor C;yy- tM — rCtfC"Address l I License No. Phone q(05-071 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION. Cl SYSTEM REPAIR ❑ OTHERX V9poLEX-1r17C-F70// We DISTANCE TO NEAREST: SEPTIC TANK IVIA SEWER LINES /\//'9 DISPOSAL FLD./� H PROP. LINE —N14 FOUNDATION '�� AGRICULTURE WELL N OTHER WELL /5 PITS/SUMPS ^7 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS // ❑ Industrial ❑ Open Bottom E Manteca Dia. of Weil Excavation ^ /O'r Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC. Specifications �� .� M Public F1 Other n Delta Depth of Grout Seal �3 Type of Grout Cremrnt/6¢,,Z. I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by-,5Ex�e lcYCa."�'Ia+ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material I[op 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthioize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance.with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. - Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. innsspectionps. Complete drawing on reverse side. 1 �7 / lq Signed Kc6ar"T- ' " �" ""t-� f •� Title: f I�/� Q/✓1 L 5 /'t.ZU'1.79-e. 77Vt �� Z t ate: /` FOR DEPARTMENT USE ONLY Application Accepted by ty-�V y t�' c I a � Date _` �Z Area L L Pit or Grout Inspection by ,Date Final/I pection by Q� Date D15 Additional Comments: :: �i(I �.1�5 LC,FN- e�.zl'1 /l a•4_,fl(�L` / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO. . EH 1124(REV.vxv '1 /�/`/ 1/ft q